23A-134 (12) 83 PINE ST- HILL INSTITUTE BP-2018-1119
cls#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:23A- 134 CITY OF NORTHAMPTON
Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category ROOF BUILDING PERMIT
Perron# BP-2018-1119
Project# JS-2018-002011
Est Cost$38000.00
Fee:$266.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sa ft.): 74052.00 Owner: Hill Institute
Zoning URB(100 Applicant TIMOTHY J LUCE
AT: 83 PINE ST - HILL INSTITUTE
ApplicantAddress: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON:4/30/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF - 50 SQRS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/30/2018 0:00:00 $266.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Roo r
Versiont.7 Conuercial Buildin Penrdt Ma 15,2000
DeparineM use only
R E C E I V L D til of Northampton Status of Dermic
B ilding Department curb cut/Driveway Permit
212 Main Street Sewer/Septic Avadabdq
APA 2 22018 Room 100 Wade/WellAvailabigry
No ampton, MA 01060 Two Sets of Structural Plans
13- 87-1240 Fax 413-587-1272 Ptnt/Site Plans
DEPT.OFBUILDING NQBIHAMPTON,MA 010a
60 Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office,
3 Map 3 Lot / 3</ Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
�'! 'rI^ry !1'L-7L0o111.,� �hrrs�!'nc1, d.cln)»P� Z3
Name(Print) Current Mailing Address.
Signature :. 1 �I'� i� )-Il' Telephone
2.2 Authorized Agent,
Name(Prim) Current Meiling Address:
�13361 ?9Q)
E gnature Telephone
SECTION 3-ESTBAATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building I's/ (a)Building Permit Fee 144
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �Y
6. Total=(1 +2+3+4+5) 1 Check Number V�
This Section For Official Use Only
Building Pennit Number Date
Issued
Sign
r
ommissoner/I for of Buildings Date
1 _
T1w � r, rvoF ���Ar WtL �rn
Versionl.7 Cor miercial Building Permit May 15,2000
SECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ fisting Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Buildingd�
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other ❑
Brief Description Enter a brief description here. tZ^'"Q- o �a�e_ra-- �`PJ(a.. rwi-
OfProposed Work: Cau.¢rrlry or` Qart,J 6 6P/�7 1/ xr -0J
SECTION 5-USE GROUP AND CONSTRUCTION TYPE �r
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A F ❑
A4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2q ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-,2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposetl Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
1° 1.
2'
2oa
3,e V
4. 4u
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height It
7. Water Supply(M.G.L.C.40,4 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑
Versionl.7 Conanercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Depamment
Lot Size
Frontage
Setbacks Front
Side LR- L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot aw minus bldg&paved
kin
#of Parking Spaces
Fill:
(volume&1,oeatmn)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 arse or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
RegRtration Number
Address
Eviration Date
Signature Telephone
9.2 Re2istered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Eviction Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Data
Name Area of Responsibility
Add,.. Registration Numbef
Signature Telephone Eviction Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Eviration Date
9.3 General Contractor
\. L. C-- �wJfr`o� Jh (-.I`C-- Not Applicable ❑
Company Name:
Responsible In GiahMe of Construction
Po B� < <ti Lem ads 3
Address
Sign' Telephone
Version N.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
c
I, 1p'�I'ICTr ' fir�I\� f as Owner of the subject property
Lhereby authorize I "^'<1 J ' o to
act on my behalf,in all matters relative to work authorized by this building permit application.
n
>II`w , bt--'tinvl � cc�L'.d �,.o 's�1wi-cr c2
Signature of own
e
r Date
I, \ � -✓c-�-- ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
'r Pyr.% J - L.v C�
Print Name
����—
Si—g�tpfc of Owner/Agent Date �
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
i
Name ML"cense Holder: I w ..-I � • L`�0+� �CSsS (�
License Number
Pct Le,�4 /'� 6167 7 -15—/r
Address Expiration Date
5;; — 913 3 a 7 yFoo
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§2SC(6))
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide this affitlavit wig result
in the denial of the issuance of the buiidin rmit.
Signed Affidavit Attached Yes No O
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: �;� S�
The debris will be transported by: I / �l
V µ�
nwr
The debris will be received by: r-§ul KeC�C�
Building permit number:
Name of Permit Applicant
J
Y/--z e
Date Signature of Permit Applicant
The Commonweahh of Massachusetts
Department of IndustrialAccidents
_ I Congress Street Suite 100
Boston, MA 02779-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:General Banfnesses.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Irlt'ormation Please Print Ltbly_
Business/OrganizationName: i-
i • L,Jca- �5}�x-��-�`-- I-(--L- ,
Address: w_12)bx lel
City/State/Zip: t-eQA 161V yl))) Phone
Are you mployer7 Check�ropriate box: Business Type(required):
1. I am a employer with employees (full and/ 5. ❑Retail
ed part-time).' 6. ❑Restaorant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no y, [3 Office and/or Sales (incl.real estate,auto,etc.)
employees working for me in arty capacity.
(No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required}* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with ��-
no employees. INo workers' comp. insurance req.] 12.fsuther
'Any applirem that checks box MI must also fill..[fiasection below shawing their workers compensation policy Infotmatiom
'Yf fhe corporate omeea have exempted themrelves,but the mrpomnon has other employees,a workerscompensation palicy Is required and such an
o1Wh,,cion shnuld check box Xl.
land an employer that Is providing workers'eampensaflon insurance for my employees. Behly is(he polleyinformation.
Insurance Company N.:_—]f gw�
.: —�_e_t( r �
Insurer's Address: ''trslP J-KS✓ K4V 7/ A�V
, J
City/State/Zip: y p i /V rte c of oteo
Policy N or Self m,Lia 8 (nH V r51 H 7)_ (i Q/7 Expiration Date z6LZ Ills
Attach a ropy of the workeri compensation policy declaration page(showing the policy num r an expiration date).
Failure to secure coverage as required under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certinder duspains and penahles ofperlury that the intonation provided above is true and correct.
Signature: �S /' Dat �
Phone 4: 3 E I �d()
O1Beial use only Do not write in this area, to be completed by city or toren official
City or Town: Permit/License 4
Issuing Authority(circle one):
I.Board of Health 2.Big Department 3.Cky/Tewn Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone It:
www-revs.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees.
Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as an individual,partnership,association,corporation or other legal entity,or any Moor more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
MGL chapter 152, §25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152,§25CH)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permiUlfcense number which will be used as a reference number.In addition,an applicant that
must submit multiple peri license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
F..Revised a2-23-15
4/26/18
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main St.
Northampton, MA 01060
1 request that you grant a modification to waive the requirement for control construction
for the project at 83 Pine Sl. in Florence, because the work is of a minor nature,will not affect
health, accessibility, life and fire safety, or structural requirements and is impractical in that the
cost of control construction is considerable when compared to the cost of the proposed work.
Thank you for your consideration.
Respectfully,
Timothy Luce
PO Box 14
Leeds, MA 01053
Massachusetts Department Of Pubitc Safety LTH OF MA'iSA
* COMMON
Board s Building Regulations and Standards • • s�s ,r Ham.;,
License: CS-t0051S "
• w. •�y7d1` d�
(:ons en_r;oo Soaen,iso, - SHEETMETAL WORKERS ..
ISSUES THE FOLLOWING UC64EAS A
TMtOTN UCE iTASYER.(INR
Po 80X 114 L4 ESTRICTED
LEEDS MA 01463 T)9t0"TKY J LUCE
PO BOX 14
LEEDS,44 Ot"JI53-0014..
M"UExpiration:
GOYnmissioner 0111612416 13395
90636
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taszea laatarm,s to P,r•Pan,-Suite 61To
TIMOTHY J LUCE Beaten,MA 0211.,6..E .,,.�•'y
TiMOTHYJ LUCE
In AUDBON RO. J
LEEDS,MA 41453 Undersecretary Not valid without Signature